Become a Volunteer Clinician

Thank you for volunteering your professional services to the Pro Bono Counseling Project.

Please complete this form and send a copy of your liability insurance to us by fax, email or mail.

Fields marked * are required

I agree to provide pro bono mental health care to (check all that apply): *

Children

Couples

Youth

Families

Adults

Groups

My areas of interest are: *

Anxiety disorders

Caregiver Needs

Cancer/Long-term physical illnesses

Career Counseling

Domestic Violence

Eating disorders

Educational testing

EMDR

Faith-based

Gay/Lesbian/Bisexual

Gender Identity

Grief

Latinos

Medications

Military Members, Veterans, and their Families

Older Adults

Postpartum Depression

PTSD

Sexual abuse

Single Parenting

South Asians and Indians

Substance Abuse

Trauma

Victims of Crime/Violence

Other

During the next 12 months I can commit to:

Number of Pro Bono cases:

About you:

First Name: *

Last Name: *

Middle Name:

Prefix: *

Suffix:

Race:

Gender:

Level of license: *

If student or graduate-level license

Supervisor Name:

Supervisor’s License:

Contact information:

E-mail Address: *

Business Phone: *

Mobile Phone:

Therapy Address:

Street: *

City: *

State: *

Zip Code:

Mailing Address:

Street: *

City: *

State: *

Zip Code:

My Office is Wheelchair Accessible: *

Yes

No

I would Prefer to Meet with Clients: *

In my Office

At Another Location

Via Teletherapy

In Clients' Homes

I am available to meet with clients:

Weekday Daytime

Weekday Evenings (6 pm or later)

Saturdays

Sundays

Supervisor:

I am available to be a Supervisor for 1 hour per week

I have Office Space for graduate students

Besides English, I also Speak:

From time to time, when PBCP receives calls from clients who have the means to pay for counseling through a combination of insurance and income, PBCP may refer them to a PBCP clinician.These referrals are not considered to be pro bono referrals. I accept :

Aetna

Amerigroup

Blue Cross Blue Shield

CIGNA

Kaiser

Tricare

United Healthcare

How did you hear about the Pro Bono Counseling Project?:

Comments:

Refer a Colleague :

Please provide two or more names, including email address and phone number, of licensed clinicians, including LG's who may be interested in joining the Pro Bono Counseling Project